Thousands of people gathered at the Lincoln Memorial in Washington, D.C., on Jan. 23, 2022, to protest vaccine mandates. (Shutterstock)

Allison Arwady never had trouble sleeping before the pandemic. Now, her mood rises and falls with local COVID-19 numbers, tracking upticks in hospitalizations and outbursts of public backlash. Outside her window, a Chicago police car still sits at the curb, stationed there around the clock to protect her.

Arwady, commissioner of the Chicago Department of Public Health, has been the face of the city’s pandemic response since COVID-19 arrived two years ago, making her the target of angry protesters and threats to her physical safety. Even now, in the relative calm of the post-Omicron surge, hostilities haven’t stopped. “Now people are calling me a murderer for easing mask requirements,” she said.

Dr. Allison Arwady

Arwady said one reason she’s remained so high-profile is to shield her staff, already drained as the pandemic enters its third year.

“Some of it is about continuity, but some is because I cannot have the personal targeting of my staff,” she said. “I worry, am I pushing people too hard, am I asking too much? I spend as much time worrying about staff and how to direct resources … as I do about Covid because you’re only as good as your team.”

What’s happening in Chicago isn’t unusual. New data released today found that 56% of nearly 45,000 public health workers in a recent survey reported at least one symptom of post-traumatic stress disorder. Twenty-five percent reported three or four symptoms, indicating probable post-traumatic stress disorder. People in executive roles, like Arwady, reported worse mental health than other public health workers.

OUR NATION’S SAFETY IS ERODING BENEATH US BECAUSE OUR PUBLIC HEALTH WORKFORCE ISN’T WELL.”

Brian Castrucci, president and CEO of the de Beaumont Foundation.

The new data comes from the Public Health Workforce Interests and Needs Survey (PH WINS), which polled workers between September 2021 and January 2022 and is the only nationally representative survey of governmental public health employees. The survey, conducted by researchers at the de Beaumont Foundation and the Association of State and Territorial Health Officials, found that 22% of public health workers reported their mental health as either “fair” or “poor.” Employees at big-city public health departments reported worse mental health than peers in other types of health departments.

Almost one-third of survey respondents said they were thinking about leaving their health departments in the next year.

“Our nation’s safety is eroding beneath us because our public health workforce isn’t well,” said Brian Castrucci, president and CEO of the de Beaumont Foundation. “These data are a warning.”

The new PH WINS survey builds on similar data reported last year by the Centers for Disease Control and Prevention. In that study, which included more than 26,000 public health department employees, more than half reported symptoms of at least one mental health condition in the prior two weeks, including nearly 37% who reported PTSD symptoms. That PTSD prevalence, according to the CDC, was between 10% and 20% higher than rates previously reported among health care workers.

Such trends could have critical implications for a sector facing down a worker exodus even before the pandemic. PH WINS data collected in 2017, for example, found that about 22% of health department workers surveyed had been planning to retire by 2023.

In Huntington, West Virginia, the Cabell-Huntington Health Department lost nine employees — or nearly a fourth of its staff — to the stresses of COVID-19 response within the pandemic’s first year, said Michael Kilkenny, CEO and health officer at the agency.

The impact was often heaviest on workers staffing the health department’s COVID-19 call center, which got hundreds of calls a day at its peak. “They’d get so much verbal abuse,” Kilkenny said. “That was very difficult to adjust to.” In response, the agency brought in mental-health support services and trained staff on de-escalation techniques.

Overall, the number of staff numbers at the Huntington health department went up during the pandemic, due to federal relief money that helped departments nationwide hire temp workers for COVID-19 response. But two years in, Kilkenny said his workforce is just now stabilizing, with those nine vacancies he incurred early on nearly filled. “The loss of cumulative knowledge is just huge,” he said.

According to the new PH WINS data, among the 32% of public health workers considering leaving their jobs soon, 39% said the pandemic made them more likely to leave. Among those thinking about leaving, the most often-cited reason was pay. Forty-one percent cited burnout and 37% said stress — both of which were higher than 2017 levels. Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials, said the data confirms what she’s heard anecdotally.

“There’s a cumulative impact on people’s mental health to being in constant preparedness and response mode this long,” Freeman said. “Then to layer on a total lack of recognition of the job being done and lives being saved. … I think a lot [of public health workers] are going to be shell-shocked when we come out of this.”

Local health departments entered the pandemic with workforce numbers down 16% since 2008, Freeman said, and lost hundreds of high-level leaders over the past two years. Such workers — responsible for a plethora of duties in addition to COVID-19, from restaurant inspections to free STD screening to water-quality testing — are also dealing with impacts of COVID-19 in their personal lives. “It can become unbearable,” Freeman said.

In the short term, she said, each agency should make sure workers have access to mental health services. In the longer term, she said, states need to modernize archaic civil-service systems if they want to recruit, retain and support public health workers. That strategy appears to be working at the Cabell-Huntington Health Department.

OVER 40% OF PUBLIC HEALTH WORKERS IN EXECUTIVE ROLES AGREED THAT THEY FELT BULLIED, THREATENED OR HARASSED BY PEOPLE OUTSIDE THEIR DEPARTMENTS, COMPARED TO 16% OF OVERALL RESPONDENTS.

PH wins survey.

To address staff losses, county officials recently authorized the local board of health to make some pay and hiring decisions without the state’s approval. The change means the health department can now post a job and make a hire within 10 days. Under the old system, it could take a month just to post an open position. It also means Kilkenny can offer more money. The old salary for a health department sanitarian, which requires a four-year degree, was $24,500; now the position pays $34,000, with the possibility of bonuses.

“It’s definitely boosted morale among staff,” he said, “because it’s real — it’s more than just lip service.”

Longtime problems like chronic underfunding undergird the distress public health workers are feeling, said Chrissie Juliano, executive director of the Big Cities Health Coalition, a forum for leaders from the nation’s largest metropolitan health departments. Extreme politicization of pandemic response is also a major contributor, she said.

The new PH WINS data found over 40% of public health workers in executive roles agreed that they felt bullied, threatened or harassed by people outside their departments, compared to 16% of overall survey respondents. Earlier this month, a study published in the American Journal of Public Health reported similar findings, identifying nearly 1,500 episodes of harassment against local health officials between March 2020 and January 2021. Officials in that study described experiences such as “marginalization of their expertise, social villainization and disillusionment.”

Juliano said she suspects health departments could face another surge in worker departures as the emergency response to COVID-19 scales down. “I think a lot of people stayed, especially leaders, because they didn’t want to leave in the middle of a crisis,” she said. “We already had a pipeline problem in governmental public health, a shrinking workforce — these [PH WINS] data will likely exacerbate that.”

Last November, after working every day for 100 weeks straight, Lee Norman stepped down as secretary at the Kansas Department of Health and Environment, following disagreements with Gov. Laura Kelly’s office about his public COVID-19 messaging.

Norman, also a colonel in the U.S. Army, said the anguish he’s witnessed among colleagues in the last two years reminds him of what he saw in soldiers returning from Vietnam decades ago: people consumed by grief, shunned for doing their jobs.

“That’s been the hardest part,” he said, “that lack of connectedness with community, with the people we worked so hard to gain trust with, let alone with our own leaders.”

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